| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,337 |
6,291 |
$138K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
891 |
249 |
$115K |
| D1206 |
Topical application of fluoride varnish |
6,954 |
6,848 |
$90K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,444 |
1,346 |
$56K |
| D0160 |
|
976 |
968 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
3,210 |
3,188 |
$50K |
| D0272 |
Bitewings - two radiographic images |
2,744 |
2,724 |
$37K |
| D1351 |
Sealant - per tooth |
1,893 |
421 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
352 |
175 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
638 |
$13K |
| D0191 |
|
961 |
913 |
$10K |
| D0240 |
|
778 |
398 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
128 |
54 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
170 |
$8K |
| D9420 |
|
13 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D1310 |
|
544 |
536 |
$0.00 |
| D0603 |
|
544 |
536 |
$0.00 |
| D1999 |
|
20 |
20 |
$0.00 |